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7 v f•ti ti •4 ' - .r 4n=uSVluldl +rl�"X7+� 7 L <br /> ADM <br /> FOR OFFICE USE: <br /> 33 APPLICATION FOR SANITATION PERMIT <br /> S a Permit No. .. <br /> + (Complete in Triplicate) t7k <br /> ......................................................... Date Issued 7 /� <br /> :. <br /> ............:...................................... This Permit Expires 1 Year From Date Issued yV�i3x^u� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work heroin� <br /> ( PP Y q <br /> < described. This application is made in compliance with County Ordinance 549 and existing Rules and Regulatiottti- <br /> s JOB ADDRESS/LOCATION ...---� �Q -F' Q 12/-- •--•......................CENSUS TRACT .......... <br /> `• #x; <br /> Ss�ts�r { Owner's Name .._..... ..Phone ..._.. <br /> r,1 �.----...re.• ..................................... . ................................. a <br /> xAddress ..:........_ Q.�j1.G. .......................City ......................:............... _. ..... <br /> t� ,er.r� <br /> y— <br /> Contractor's Name ....... �� B�-1-{i/".....................License#/��V.l�i�... Phone <br /> K Installation will serve: Residence XApartment House Q Commercial QTrailer Court Q <br /> Motel ❑Other ------------------------• .................. }: <br /> h Number of living units: .�.... Number of bedrooms ........Garbage Grinder &V.. Lot Size .......... { <br /> Water Supply: Pv51ic System and name ........................................................_.............._....__............._._.... ......Pnvate�z, <br /> ~' Character of soil to a depth of 3 feet: Sand�] Silt❑ Clay ❑ Peat Q Sandy Loam ❑ Clay loam ❑ <br /> Hardpan Adobe ❑ Fill Material ......:.....If yes,type...__..... t ; <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on revmo side J'a(t"� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) rry oIs' <br /> w`$ <br /> PACKAGE TREATMENT_ [ ] SEPTIC TANK j ] Size................................... I.........Liquid Depth ......r " ''t•»• ' <br /> `Capacity Type . Material.. _... No. Compartments <br /> .......-•--........ .__....____•__..... ---•--.......... <br /> ' Prop. Line Vic; O. <br /> Distance to nearest: Well _::'................................Foundation ...................._ •• ?�t.1• <br /> a LEACHING LINE [ ] No. of Lines --------- ------------- Length of each line............................ Total Length <br /> 'D' Box ..... .... Type Filter Material ....................Depth Filter Material <br /> Distance to'nearest: Well .............:.......... Foundation Property Line <br /> SEEPAGE PIT [ ) Depth :................... Diameter ..........._....•Number ............................ Rock Filled Yes C] No <br /> Water Table Depth .. .. .....................................Rock Size ------........_................ <br /> r <br /> Distance to nearest: Well .... .......... Foundation .................... Prop. Line ......... ......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .................... <br /> . .. Date ...... <br /> .... <br /> Septic Tank (Specify Requirements) ............:.lf' Q f-----------•to ........1,-f..... �.�1+1�.�. <br /> .;y <br /> Disposal Field (Specify Requirements) ........ ..--...�� � ��eL- F ..................................................... <br /> Itr <br /> i <br /> (Draw existing and required addition on reverse side) <br /> ij I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or lion- <br /> sed agents signature ceMfies the following: <br /> ' "I certify that In the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laves of Cal ornia." -•j- <br /> Signed ... ........... ....... .............. . ... .... ... ....... Owner <br /> -� .i <br /> f. By ..... ....... b/(��- ��6e��G Title .......�j/t���/tj.-.'.... ......... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ? APPLICATION ACCEPTED BY... /lTaGs� .........................:.................................. DATE 'R <br /> ' - ........_...................-........DATE ..._......_..._............_........_...... <br /> BUILDING PERMIT ISSUED . .........................................................._-. <br /> ADDITIONAL COMMENTS ' <br /> r• <br /> _......_... <br /> a- <br /> :_....,�. .ter»/' 1�... . . _......._._.._.....Date ........... <br /> Final Inspection by: ............_..............._............. ......... . . ..... .-.. <br /> SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1•'68 Rev. 5M <br />